Accidental ingestion of orthodontic band loop

Case report

A 13-year-old female patient had a Class II division 1 malocclusion with a constricted maxillary arch. Rapid maxillary expansion (RME) with banded RME was planned as the initial treatment. Whilst preparing the band on the upper right first premolar, the band loop (Figure 1) slipped from the hand and passed into the pharynx. The oral cavity and pharynx were examined and the band material was not found. However, the patient had no respiratory difficulties. An anaesthetist and a gastro-enterologist were consulted as a matter of urgency and the patient and her parents were given an explanation of the situation. Also, a PA view radiograph of the chest was recorded. The radiograph revealed the presence of band material in the stomach (Figure 2). The patient was asked to eat bananas and to check the stools every day. The patient was reviewed the next day with a radiograph taken of the abdomen. The radiograph revealed the presence of band material in the small intestine (Figure 3). On the third day after the incident, again a radiograph of the abdomen revealed the presence of band material in the large intestine (Figure 4). On the fifth day, the radiograph of the abdomen confirmed the absence of band material in the abdomen (Figure 5) However, the band loop was neither seen nor retrieved from the stools. The patient remained asymptomatic during the observation period.

Discussion

Any episode of foreign body ingestion in any branch of dentistry has the potential to result in acute medical and life-threatening emergencies.³ Prevention of such an incident by the mandatory use of precautions during all dental procedures is the best approach.¹⁵ The orthodontist and general dentists must be able to recognize the signs and symptoms of any airway obstruction in case a dental object is lost into the oropharynx. If an object gets dropped into the mouth in a supine patient, the patient should not be allowed to sit up immediately and the head of the patient should be turned to one side to encourage the object to fall into the cheek and not into the oropharynx.³ Alternatively, the patient could be turned face down.¹⁶ This encourages an object in the oropharynx to return to the patient's oral cavity so that it can be recovered. Also, the patient should be asked to cough.¹⁷ The mouth and oropharynx should be examined and, if the object is visible, it should be removed either with forceps¹⁷ or with high-speed suction.¹⁸ Cameron et al advised that either forceps or high-speed suction should be available during all dental procedures.³ The most readily visible site for the entrapment of a foreign body that has become displaced in the oropharynx is the supratonsillar recess, followed by the epiglottic vallecula and the piriform recess.¹⁹ If the foreign body is found in these areas, the retrieval, identification and confirmation of that object should be followed immediately by reassurance of the patient.¹⁹ If the foreign body is not found, it should be assumed that it has either been swallowed or aspirated. If airway compromise is noticed, a Heimlich manoeuvre²⁰ should be performed in an attempt to relieve the laryngeal obstruction. If the Heimlich manoeuvre fails, immediate medical emergency help must be summoned. If a patient's airway is not compromised, the patient should be informed that he or she has swallowed the foreign body.

The majority of the foreign bodies entering the oropharynx usually pass into the alimentary canal and pass in the stools without complication.²¹ There is, however, always a danger of perforation of the gut, which can have very serious consequences, including death.²² Only large objects and those with sharp edges are liable to become impacted in the oesophagus and, if this happens, it usually happens at the level of the fourth cervical vertebra.⁹ The inability to swallow, muscle inco-ordination, pain on swallowing, haematemesis and vomiting, etc are common symptoms of oesophageal obstruction. This can also lead to oesophageal perforation with secondary mediastinitis.⁴ Once the foreign body reaches the stomach, it has an 80–90% chance of passing through the gut without problems.^9,21,22 The usual time taken for a foreign body to transverse the intestinal tract is 2–12 days.⁹ Radiographic monitoring of the progress is, however, very important. The management of patients who have swallowed foreign bodies relies on regular assessment and serial radiography. Radiographs not only allow the clinician to confirm the presence of a foreign body, but also help to assess its size, shape and position and to look for indications of intestinal perforation, such as pneumoperitoneum. During the episode, the patient can be advised to supplement his/her diet with a large amount of cellulose, which will aid passage of the object through the gut.^12,23 In the present case, we advised the patient to eat more bananas as they contain a large quantity of fibre. Use of a high-bulk diet may be helpful, however, there is no scientific evidence of the benefit of any special diet to support such an object's passage. Purgatives should be avoided because they increase the peristaltic contraction and thus increase the chance of intestinal perforation.²⁴ Induction of emesis should be avoided when the foreign body is present in the stomach as there is always a danger of aspiration.¹⁷ For radiolucent objects, ingestion of cotton wool pellets mixed with a small amount of barium sulphate suspension has been reported to form a radio-opaque bolus around the object, which allows it to be tracked through the gut radiographically.¹⁷

Less than 1% of ingested foreign bodies can cause a perforation,^12,25 however, individual articles reported a 4.5%²⁶ and 5.6%²⁷ incidence of perforation. Sharp pointed objects are associated with a higher risk of perforation. Objects longer than 5 cm are unlikely to pass the duodenum. Areas of physiological or pathologic narrowing, such as the pylorus, the ligament of Treitz, the ileo-caecal valve, the rectosigmoid junction and the anus are potential sites of impaction.^28,29,30 The commonest sites for perforation to occur are the ileo-caecal junction and appendiceal areas.²⁸ Also, the risk of obstruction increases in patients with abnormal intestinal anatomy, such as strictures. The symptoms of abdominal perforation include abdominal pain, fever, nausea, vomiting and abdominal distension.^22,25

Recommendations

There are many consequences of foreign body ingestion, thus all precautions should be considered to prevent the ingestion or aspiration of a foreign body in day-to-day dental practice. The general precautions include the following.

Guidelines for planning for endoscopic removal of foreign bodies

When managing a patient with foreign body ingestion, two important questions must be addressed:

Factors which should be considered in addressing these questions include:

Conclusion

The management of patients who have swallowed foreign bodies relies on regular assessment and serial radiography. The patient should be evaluated for symptoms of intestinal perforation or obstruction. Provided that the patient is asymptomatic, a waiting policy can be adopted and the stools examined regularly for the presence of the foreign body. However, consultation with a gastro-enterologist is very important as endoscopic removal of the object may be a possibility.